Lorazepam is the most appropriate treatment for this patient with alcohol withdrawal and chronic liver disease. Alcohol withdrawal symptoms can start within 4 hours to several days after the last drink. Alcohol activates the same receptor as γ-aminobutyric acid, which is the major inhibitory neurotransmitter in the brain, causing central nervous system depression. If ethanol has been present frequently enough in a heavy drinker to develop tolerance and dependence, sudden withdrawal creates a state of central nervous system hyperactivity, which can be life threatening. Early symptoms include agitation, tremulousness, headache, and symptoms of autonomic hyperactivity (fever, diaphoresis, tachycardia, and hypertension). As withdrawal becomes more severe, patients may experience seizures and/or hallucinations, usually within 12 to 24 hours of abstinence. Delirium tremens is a systemic syndrome characterized by hypertension, tachycardia, diaphoresis, fever, disorientation, and hallucinations. Onset is usually 48 to 96 hours after the last drink and sometimes persists for many days. Benzodiazepines are the treatment of choice for alcohol withdrawal. Thiamine, glucose, and folate are supplemented routinely, and nutrition should be instituted early.

All benzodiazepines appear similarly efficacious in reducing signs and symptoms of alcohol withdrawal. Longer-acting agents, such as chlordiazepoxide, may be more effective in preventing seizures but can pose a risk for excess sedation in older adults and patients with marked liver disease, such as this patient. Short-acting benzodiazepines, such as lorazepam, are preferred to long-acting benzodiazepines in patients with liver disease because short-acting benzodiazepines cause less metabolite buildup in the liver. In this patient, benzodiazepines will not only help to control his current symptoms but will also help to prevent him from progressing to severe alcohol withdrawal.

Clonidine and β-blockers such as propranolol have been used as an adjunctive therapy in alcohol withdrawal because they reduce withdrawal symptoms related to autonomic hyperactivity. However, there is little evidence that either of these medications reduce or prevent seizures and delirium.